Responding to criticism

In defence of traditional birth attendants

In September, the D+C/E+Z focus section on maternal health included an essay by Rafiqul Huda Chaudhury and Zafrullah Chowdhury of Gonoshasthaya Kendra (GK), a health-sector NGO in Bangladesh. The authors reported how GK managed to reduce rural maternal mortality by training and organising traditional birth attendants (TBAs). Their elaborations triggered a letter from three international health experts based in Dhaka. The letter was published in our December edition, and its main point was that, according to international standards, TBAs should not be entrusted with delivering babies. Rather, professionally trained “skilled birth attendants” (SBAs) should do the job. Accordingly, the Dhaka-based experts from KfW, GTZ and ICDDR praised the policy of the Government of Bangladesh, which emphasises professional training. The two leaders from GK felt compelled to reply.

[ By Rafiqul Huda Chaudhury and Zafrullah Chowdhury ]

First and foremost, we thank Mr. Dirk Gehl of KfW, Mr. Jean-Olivier Schmitz of GTZ and Dr. Tracey Perez Koehlmoos of ICDDR, Dhaka for suggesting a comparative study of GK Health Workers and trained TBAs with the work of qualified SBAs in Bangladesh. The suggested comparative study should evaluate their
– attitude and performance in antenatal care (ANC) and postnatal care (PNC),
– willingness, persuasion ability and skill in home-delivery,
– results in terms of mothers’ breast feeding of neonates,
– management of obstructed labour, threatened abortion, eclampsia, pre-eclampsia and hemorrhage and prompt referral to public (government) health centres in case of need,
– determination of caring for – and empathy with – pregnant women from poor social classes,
– adherence to protocols for assisted delivery at home,
– cooperation with SBAs and
– cost-effectiveness.
GK will provide all support for such a comparative study to determine outcomes of home delivery by trained TBAs and SBAs, provided KfW, GTZ and ICDDR organise/finance such a study under the guidance of a team of independent academics and knowledgeable practioners.

We do not know, whether Mr. Gehl, Mr. Schmitz and Dr. Koehlmoos have actually observed many home deliveries by TBAs in rural Bangladesh or not. If they wish, GK will happily organise a visit for them to observe firsthand some home deliveries by trained TBAs in villages.

It is often difficult for foreign-based experts, and even those based in Dhaka, our capital city, to understand local culture, tradition and needs. In 1972, when GK started training young rural women with six to ten years of schooling to conduct basic diagnostic measures and intervention and treatment of common diseases, professionals with national and international state of knowledge raised a hue and cry, even questioning the wisdom of allowing health workers to own, carry and use blood pressure (BP) machines. Professional nurses in Britain only got the official permission in 1994 to carry out some tasks GK health workers have been performing in Bangladesh since 1972.

To know more about abilities of health axillaries, please read “Tubectomy by para-professional surgeons in rural Bangladesh”, published in the Lancet, 27 September 1975. While Europe, including Britain, is moving towards home delivery of babies, foreign consultants in Bangladesh, ignoring local culture, tradition and financial implications, are promoting institutional delivery. For this reason, they often provide half backed or twisted information. Moreover, they are not familiar with troubled governance and the lack of accountability prevalent in Bangladesh’s public sector.

Indeed, “the debate over traditional versus health care” is relatively recent in Bangladesh in comparison to that in Europe and North America. We should not forget TBAs in Europe were burnt as witches even in early twentieth century; midwives in North America were debarred from home deliveries till the 1940s due to crusades of professional bodies and medical journals. Even today, medical professionals in Europe and America grumble against work done by SBAs on their own.

Exclusive professionalism
Professionals, due to their self-interest, will always “doubt” common people’s ability and skill. Professionals always feel threatened by other groups such as TBAs who work with ethical drive, motivation and social commitments. One of us has worked with hundreds of TBAs in the past 37 years, and never found a TBA asking for money before helping to deliver a baby. Nor do the TBAs bargain for fees. They believe that timely delivery even at odd hours of the night, is their moral obligation and social duty. Acquiring skills through observation, apprenticeship and practice is the first step towards the demystification of so-called professional health care.

Surely, TBAs have some failures, which will decrease substantially not by condemning them but by giving them five to seven days’ training and yearly refreshers courses. In our experience, more maternal mortality occurs at public and private health centres due to absenteeism of doctors and other skilled workers, even when TBAs referred in time, helped organise the transport and even accompanied distressed women to the clinics. There have been many examples of professionals failing to provide prompt help when a family could not pay enough. TBA shortcomings pale in comparison.

In the past, a TBA training programme run by UNICEF and other donors failed because of faulty selection processes and inadequate training places. In reality, TBAs were not selected for training. Instead, the chosen were young women with no previous experience in child birth. All training centres were located in Dhaka and some district towns, but not in rural areas. Right from the start, the programme had built-in failures.

Present SBA training, moreover, has striking similarities with the failed TBA training programme. Most SBAs are former family-planning workers whose job was to prevent conception, not to promote pregnancy. Before training, none of the SBAs had experience of delivery at home. They are familiarised with institutional delivery, though their supposed job is to conduct home delivery in rural areas of Bangladesh. As most SBAs do not feel confident to conduct home deliveries, they discourage home deliveries, and refer pregnant women mostly to private clinics from which SBAs benefit financially.

At present, around 10 % of the deliveries are conducted in government hospitals and clinics, where negligence and inhuman treatment are quite common, as Bengalis read in the newspapers day by day. In defence, physicians take refuge in the shroud of shortage of staff and funds. On the other hand, over 80 % of the deliveries in Bangladesh are attended by TBAs at families’ homes with no cost involvement for the government. Consider what would happen if all home deliveries were converted into institutional deliveries.

Our focus is to train TBAs to recognise danger signs and to refer promptly. Give them mobile phones so that they can consult doctors promptly. Trust them to prescribe Misoprostol orally, rectally and vaginally. Ideally, all TBAs should be trained to become SBAs. But as long as there are not enough SBAs and the governmental health-sector’s incentive problems remain unsolved, training TBAs is certainly the best choice.

The real challenges
Let’s not debate commonsense. It is not the TBAs fault that maternal mortality in Third World countries is not declining fast enough. The real problem is the absence of professionals and/or inadequate facilities at state-run and private clinics – as well as, to some extent, delay in taking decisions by the family concerned and difficulties of arranging transport. That is what data from GK programme villages suggest.

GK data (Chaudhury and Chowdhury, 2008) also show that the percentage of deliveries attended by medically trained personnel is higher for women who died from complications related to pregnancy and child-birth than for those women who delivered safely (22 % versus 2.6 %). Consistent with the above findings, data also show a higher proportion of maternal deaths (49 %) occurring in hospitals or clinics than at home (37%).

More doctors and more professionals do not necessarily guarantee better health care. “Caring health care for all” can only be achieved by genuine political commitment, a good number of physicians backed by many times more health workers (including trained TBAs and SBAs) – all with humane attitudes and caring services and ensuring accountability of health service providers to the community in which they work under the supervision of elected local Government. Skills development must not be the monopoly of the professionals.

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